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Health Assessment Chapter 25. Competencies for Ch 25, Health Assessment. By the end of this unit, the student will: Demonstrate techniques to obtain patient information Describe the components of a health assessment Describe how to prepare the patient for the exam

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competencies for ch 25 health assessment
Competencies for Ch 25, Health Assessment
  • By the end of this unit, the student will:
    • Demonstrate techniques to obtain patient information
    • Describe the components of a health assessment
    • Describe how to prepare the patient for the exam
    • List the equipment needed for an examination
    • Demonstrate a brief head to toe physical assessment
health assessment
Health Assessment
  • Two components of the health assessment
    • Health History
    • Physical Assessment
what happens during a health assessment between a patient and nurse
Establish the nurse-patient relationship

Gather data-physiological, psychological,cognitive, sociocultural, developmental, spiritual

Identify patient strengths

Identify actual and potential health problems

Establish a base for the nursing process (Assessment)

What happens during a health assessment between a patient and nurse?
general guidelines for physical assessment
General Guidelines for Physical Assessment
  • Instrumentation
  • Positioning
  • Draping
  • Preparation of the environment
  • Patient preparation
  • Techniques of physical assessment
positioning
Sitting –used in an upright chair or dangling off exam table

Supine-lie flat on your back

Dorsal recumbent-lie back with knees bent

Sims’s-lies on either right or left side lower arm behind the body and the upper arm is bent at the shoulder and elbow and knees are both bent

Positioning
  • Prone-Pt. Lies on abdomen
  • Lithotomy- patient is in a dorsal recumbent position with buttock at the edge of the examining table and feet support in stirrups.
  • Knee to Chest-using the knees and chest to bear the weight of body.
  • Standing
draping preparing the environment
Draping prevents unnecessary exposure, provides privacy, and keeps the patient warm during the physical exam (P.E.).

Prepare examination table

Place a gown and drape on the table

Set up any supplies that are needed.

-Example: otoscope, tuning fork, ophthalmoscope.

Pull curtain around or close door to exam room

Draping, preparing the environment
techniques for examination
Inspection- observing, listening or smelling to gather data

Palpation-assessment that uses sense of touch

Percussion-act of striking on e object against another to produce a sound

Auscultation-act of listening with a stethoscope to sounds produced with in the body.

Techniques for examination
inspection
Deliberate, purposeful, observations in a systematic manner

Nurse use the physical senses: visualizing, hearing, and smelling

Inspection
instrumentation or equipment used for inspecting
Ophalmoscope-

Exam the eyes

Otoscope- examine the ears, mouth and nostrils

Tuning fork - hearing

Nasal speculum-visualized the turbinates of the nose

Stethoscope

Instrumentation or Equipment used for inspecting
palpation technique using the sense of touch
Palpationtechnique using the sense of touch
  • The hands and fingers are sensitive tools and assess:
    • Temperature- use the dorsum of the hand
    • Turgor
    • Texture
    • Moisture
    • Vibrations
    • Shape

Use the palmer (front side) of the hand

percussion the act of striking one object against another to produce a sound
Percussion tones are used to assess location, shape, size and density of tissue

Percussion Tones

Flat

Dull

Resonance

Hyper resonance

Tympany

Percussion-the act of striking one object against another to produce a sound
auscultation act of listening with a stethoscope to sounds produced with in the body
Auscultation-act of listening with a stethoscope to sounds produced with in the body
  • Four characteristics assessed by auscultation
    • Pitch- ranging from high to low
    • Loudness- ranging from soft to loud
    • Quality- gurgling or swishing
    • Duration (short, medium, long)
general survey
Gather information regarding

Patient\'s appearance, behavior

Measuring vitals signs

Height, and weight

General appearance

Gender and race

Body build, posture and gait

General appearance

Hygiene, grooming (note body odor, cleanliness).

Signs of illness

Affect, mood, attitude (speech and facial expressions)

Cognitive process (speech content, patterns, orientation, appropriate verbal responses)

General Survey
vital signs height and weight
Take Vital signs (VS) and determine normal or abnormal -document

Height and weight- document

(Check the height and weight table to determine if a patient is under, normal or over weight.)

Vital Signs, Height and Weight
physical assessment head to neck
General survey

Height and weight

Vital Signs

Neck

Skin

Lymph nodes

Muscles

Thyroid

Trachea

Carotid arteries

Neck veins

Physical Assessment Head to Neck
  • Head
    • Skin
    • Face, skull, scalp, hair
    • Eyes
    • Nose and sinuses
    • Mouth and or pharynx
    • Cranial nerves
integument structures
Skin

Nails

Hair

Scalp

Obtain history of rashes, lesions, changes of color or itching

History of bruising or bleeding

Exposure to sun

Note presence of wounds, abrasions

Changes in mole size, shape or color

Integument structures
slide19
Inspect for color, vascularity, lesions and body odors

Color-pinkish white to various shades of brown.

SKIN
head and neck
Assessment includes

Skull

Face

Eyes

Ears

Nose

Sinuses

Mouth

Head and Neck
  • Pharynx
  • Trachea
  • Thyroid glands
  • Lymph nodes
skull and face
Inspect size and shape

Symmetry

Face- examine color

Symmetry

Distribution of facial hair

Assess facial nerve and facial muscles-

Skull and face
eye and ears
EYE

Inspect external structures

Pupils and Iris

Internal structures

Vision

Extra ocular movement

Peripheral vision

EAR

Inspect external ear for shape, size, location bilaterally, ear should be smooth

Gently palpate ear for pain, edema, or presence of lesions

Check hearing

Inspect internal ear

Eye and Ears
nose and sinuses
Nose

Inspect size, shape and location

Check for patency (open air passageways.)

Inspect using otoscope nares and turbinates

Sinuses

Inspect the sinuses and gently palpate maxillary bone and frontal sinus

Normally the sinuses are not painful.

Nose and Sinuses
mouth and pharynx
Composed of many structures

Lips, tongue, teeth, gums hard and soft palate,salivary gland, tonsillary pillars, and tonsils

Equipment needed:

Penlight, tongue blade, 4X4 gauze sponge, and gloves

MOUTH AND PHARYNX
slide37
Trachea- note location

Midline at the suprasternal notch

Thyroid- thyroid is normally not palpable. Palpate for size shape, symmetry tenderness and presence of any nodules

Lymph nodes

Generally not palpable

If palpated, should be small mobile, smooth non-tender

Abnormal- enlarged, indicate infection, autoimmune, or metastasis of cancer

Neck
course objectives
COURSE OBJECTIVES
  • Students will learn:
  • Components of a health assessment
  • To prepare the patient for the exam
  • What equipment is needed for the exam
  • A variety of techniques to obtain patient information
  • How to examine the patient head to toe
health assessment1
HEALTH ASSESSMENT
  • Two components of the health assessment
    • Health History
    • Physical Assessment
what happens during the assessment
WHAT HAPPENS DURING THE ASSESSMENT
  • Establish the nurse patient relationship
  • Gather data in the following areas
    • Physiological
    • Psychological
    • Cognitive
    • Sociocultural
    • Developmental
    • Spiritual
  • Identify patient strengths
  • Identify actual and potential health problems
  • Establish base for nursing process
general guidelines
GENERAL GUIDELINES
  • Instrumentation
  • Positioning
  • Draping
  • Preparation of the environment
  • Patient preparation
  • Assessment techniques
positioning1
Sitting – use upright chairor dangle of exam table.

Supine – flat on the back

Dorsal Recumbant – on back with knees bent

Sim’s – lie on side, lower arm behind back, upper arm bent at the shoulder and elbow, knees both bent

POSITIONING
pulmonary
PULMONARY
  • HISTORY
  • INSPECTION
  • PALPATION
  • PERCUSSION
  • AUSCULTATION
  • BREATH SOUNDS
cardiovascular
CARDIOVASCULAR
  • History
  • Inspection
  • Palpation
  • Auscultation
  • Heart sounds
  • Peripheral vascular system
breast axilla
BREAST/AXILLA
  • History
  • Inspection
  • Palpation
abdomen
ABDOMEN
  • History
  • Inspection
  • Auscultation
  • Percussion
  • Palpation
genitalia
GENITALIA
  • Female
    • History
    • Inspection
  • Male
    • History
    • Inspection
musculoskeletal
MUSCULOSKELETAL
  • History
  • Inspection
  • Palpation
  • Testing
    • Tone
    • Strength
  • Bones and Joints
neurological
NEUROLOGICAL
  • History
  • Mental Status
    • Orientation
    • Level of Consciousness
    • Memory
    • Abstract Reasoning
    • Language
crainial nerves
Olfactory (I)

Optic(II)

Oculmotor (III), Trochlear(IV), Abducens(V)

Trigeminal(VI)

Hypoclosseal (VII)

Facial (VIII)

Acuoustic (IX)

Glossopharyngeal (X)

Vagus (XI)

Accessory (XII)

CRAINIAL NERVES
sensory motor function
SENSORY MOTOR FUNCTION
  • Motor
  • Balance and gait
  • Coordination
  • Sensory
reflexes
REFLEXES
  • Abdominal
  • Babinskis
  • Bicepts
  • Triceps
  • Patellar
  • Achilles Tendon
ad